Robotic Partial Nephrectomy for Complex Kidney Tumours: Can the Kidney Still Be Saved?

When a scan shows a kidney tumour that is large, buried deep in the kidney or close to the main blood vessels, many people are told the whole kidney must come out. Sometimes that is right. But in a good number of cases the kidney can still be saved, if the surgery is planned carefully and done by a team experienced in it. This guide explains what makes a tumour complex and what decides the answer.

Key points

• A tumour is "complex" because of where it sits and how it relates to the kidney's vessels and drainage, not only because of its size.
• Many complex tumours can still be removed with the kidney preserved, using robotic techniques and careful planning.
• The cancer comes first: if keeping the kidney would risk leaving cancer behind, removing the kidney is right.
• Planning on good-quality scans, and discussing the plan beforehand, makes a big difference.

What makes a kidney tumour complex?

• Size: larger tumours, particularly above 4 to 7 cm.
• Depth: tumours that are mostly buried inside the kidney (endophytic) rather than bulging out of it.
• Position: close to the hilum, where the main artery and vein enter, or to the collecting system that drains urine.
• Number: more than one tumour, or a tumour in a kidney that is the only one.
• Kidney health: existing kidney disease, which makes every bit of kidney tissue count more.

Surgeons use scoring systems (such as the RENAL or PADUA score) to describe this complexity. They help predict difficulty and risks, but are not rules.

What goes into the planning

• High-quality CT or MRI, sometimes made into a three-dimensional model to see the vessels around the tumour.
• Kidney function tests, including how much each kidney is doing.
• Looking for spread into the kidney vein or beyond, which would change the plan.
• Your other conditions, such as diabetes, high blood pressure and blood thinners.

How the operation protects the kidney

• Ultrasound inside the body to find the edges of a buried tumour.
• Controlling the blood supply to the tumour area, often just the branch that feeds it, and limiting the time the kidney has no blood flow.
• Fluorescent dye (ICG) in some centres, to show which parts of the kidney are well supplied.
• Layered repair: the opened part of the kidney is closed in layers to stop bleeding and urine leaks.

When removing the whole kidney is the better choice

• The tumour has grown into the main vein or beyond the kidney.
• It involves so much of the kidney that the remainder would not work well.
• The cancer is so close to the vessels that a complete removal is not possible without risk.
• You are not well enough for a longer, more complex operation.

Choosing a radical nephrectomy in these situations is not a failure. It is the safest way to remove the cancer.

Risks to discuss

• Bleeding, which may need a transfusion, and rarely a repeat procedure.
• Urine leak from the repaired kidney, which usually settles with a drain or stent.
• Short-term drop in kidney function, which may partly recover.
• A cut edge that is not completely clear of cancer. Most do not lead to recurrence, but they are watched with follow-up scans.
• Conversion to open surgery, or to removing the whole kidney, if the situation requires it.

Questions to ask

• Why is my tumour considered complex, and is keeping the kidney realistic?
• How many of these operations are done here, and how often is the kidney kept?
• What happens if the kidney cannot be saved during the operation?
• How much of my kidney function is expected to remain?

For the basics, read partial versus radical nephrectomy and robotic partial nephrectomy. For your own scans, you can ask for a second opinion, and see the kidney cancer treatment page.

This article is general information. It does not replace advice from your own doctor, who knows your reports and your health.